By R Mohindra, S Louw

Our paper is primarily an audit of the Newcastle upon Tyne Hospitals Clinical Ethics Advisory Group (CEAG). But it has several threads including:

1. The nature of the workflow for the clinical ethics committee including volume and complexity over time;
2. The impact of the relatively recent changes, including principles of approach, on the work and workings of the clinical ethics committee;
3. The place of casuistry in clinical ethics practice;
4. the possibility of developing a set of sentinel cases to make the clinical ethics committee (CEC) think more coherently about cases across a case set

These threads combine to focus on a single point:

Going forwards, what, if any, is the role of clinical ethics services within the NHS?

The data – proving work and demand but not proving benefit

The nature of the CEC workflow is set out in some detail in the paper as are the impacts of changes over time. Paediatrics is one area where the benefit of an external independent perspective that is able to accommodate medical, legal and ethical perspectives is becoming more and more valued.

Although the data gives an account of work, proving benefit is harder. However this work can form the basis from which future work can proceed. This includes a need to assess the impact of the CEC and clinical ethics support services (CESS) generally and from the view point of users of the service.

The CEC and patients

Direct engagement with the patient/family (or in fact any other user of the service) was a natural development of a service that historically emerged to help clinicians facing complex ethical dilemmas. But times change. The recognition of this led to the revision of the principles that underpinned CEAG’s approach, consequently significantly increasing CEAG’s workload.  It is worth looking at Supplement 1 for the nature of the changes that have been implemented, along with their justifications.

Valuing clinical ethics services

Clinical ethics support services are not generally valued within the NHS. This is in stark contrast with other countries, such as the USA. Our services are not generally funded, or, if funded, not adequately funded. A key driver of the audit at this level was to discover whether the volume and nature of work was such that there could be a case made to the NHS that there was a need to resource these services better. The article provides some data that may serve to promote the argument.

The CEC and the Organisation

In order to serve patients everywhere with equal quality provision there may be a case for concentrating such services into hubs with spokes to support regional or national units.

One unspoken principle is alignment. The CEC or other CESS needs to have its interests aligned with the interests of patients, not with the interests of their host Organisations. One problem facing CEC embedded within a Trust (comprising one or several hospitals under management of a quasi-autonomous Board and Executive) is that it can create conflicts of interest. Note how good leadership has been argued to be important to achieving a successful clinical ethics service. In this context good leadership is more than skills in clinical ethics. There needs to be moral courage too. It is this that allows the CEC to speak truth to power (Organisation management) when required. One way to ameliorate this burden and provide additional value from CESs may be to have them resourced from regional or even national sources, i.e. from outside the Organisation.

The ethics of the CEC: Phronesis and case based reasoning

Aristotle’s view that phronesis comes with practice and time surely is a truism. The long-serving nature of membership of CEAG was crucial to its function.  Thus specialisation is one possible way to proceed here.

The authors shared a view that case based reasoning was a way to make CEAG deliberations more coherent across cases over time. Whilst case based reasoning does have the potential to do this, there is a question about the source of the ethical content of any such deliberations. This will require more work, but a coherent case set, as crystallised here in the case digest, might be enough to bootstrap the idea towards practice at first in our own CEAG and then perhaps more widely.

The reason for asserting that phronesis in clinical judgement differs from phronesis in ethical judgement is that: (a) whilst there are value judgements in clinical decision making, clinical decision making is grounded in the empirical science and practice of medicine; and (b) whilst ethical judgements are cognisant of medical science where relevant they are not predominantly grounded in that empirical domain.

Paper title: Report on an audit of two decades’ activities of a Clinical Ethics Committee – the Newcastle upon Tyne Hospitals NHS Foundation Trust Clinical Ethics Advisory Group (CEAG)

Authors: Raj K Mohindra and Stephen J Louw

Affiliations:

RM: Chair, Clinical Ethics Advisory Group, The Newcastle upon Tyne Hospitals NHS Foundation Trust

SL: Previous chair and current member, Clinical Ethics Advisory Group, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Emeritus Consultant Physician, The Newcastle upon Tyne Hospitals NHS Foundation Trust

Competing interests:RM is a Trustee of the UKCEN and IME, SL is a previous Chair and trustee of the UKCEN